Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Diagnosis

Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / Singhal, Geeta / McDonald, Kathryn / Singh, Hardeep / Newman-Toker, David

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura


CiteScore 2018: 0.69

SCImago Journal Rank (SJR) 2018: 0.359
Source Normalized Impact per Paper (SNIP) 2018: 0.424

Online
ISSN
2194-802X
See all formats and pricing
More options …

Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of chest pain and shortness of breath

McCall Walker / Karen M. Warburton / Joseph Rencic / Andrew S. Parsons
  • Corresponding author
  • University of Virginia, Department of Medicine, 1215 Lee Street, Charlottesville, VA 22903-1738, USA, Phone: +4236201398
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2019-07-20 | DOI: https://doi.org/10.1515/dx-2019-0030

Abstract

Background

Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with likely and “can’t miss” diagnoses may reduce such errors.

Case presentation

A 57-year-old man was sent to the emergency department from clinic with chest pain, severe shortness of breath, weakness, and cold sweats. Further investigation revealed multiple risk factors for coronary artery disease, sudden onset of exertional dyspnea, and chest pain that incompletely resolved with rest, mild tachycardia and hypoxia, an abnormal electrocardiogram (ECG), elevated serum cardiac biomarkers, and elevated B-type natriuretic peptide (BNP) in the absence of left-sided heart failure. He was treated for acute coronary syndrome (ACS), discharged, and quickly returned with worsening symptoms that eventually led to a diagnosis of submassive pulmonary embolism (PE).

Conclusions

Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts at two institutions, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid premature closure and diagnostic error. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of diagnostic schema as an analytic reasoning strategy to assist in the creation of a differential diagnosis, problem representation to summarize updated findings, a Popperian analytic approach of attempting to falsify less-likely hypotheses, and matching pertinent positives and negatives to previously learned illness scripts. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to premature closure.

Keywords: assessment of fit; clinical reasoning; cognitive dissonance; diagnostic schema; illness script; problem representation; pulmonary embolism

References

  • 1.

    Popper K. The Logic of Scientific Discovery. Print. Abingdon-on-Thames, 1934 in German, 1959 in English. 513 pages.Google Scholar

  • 2.

    Reilly JB, Myers JS, Salvador D, Trowbridge RL. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis. 2014;1:167–71CrossrefPubMedGoogle Scholar

  • 3.

    Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients with acute pulmonary embolism. Am J Med 2007;120:871–9.PubMedWeb of ScienceCrossrefGoogle Scholar

  • 4.

    Gantner J, Keffeler JE, Derr C. Pulmonary embolism: an abdominal pain masquerader. J Emerg Trauma Shock 2013;6:280–2.PubMedCrossrefGoogle Scholar

  • 5.

    Altınsoy B, Erboy F, Tanrıverdi H, Uygur F, Örnek T, Atalay F, et al. Syncope as a presentation of acute pulmonary embolism. Ther Clin Risk Manag 2016;12:1023–8.CrossrefPubMedGoogle Scholar

  • 6.

    Majidi A, Mahmoodi S, Baratloo A, Mirbaha S. Atypical presentation of massive pulmonary embolism: a case report. Emergency 2014;2:46–7.PubMedGoogle Scholar

  • 7.

    Douma RA, Gibson NS, Gerdes VE, Büller HR, Wells PS, Perrier A, et al. Validity and clinical utility of the simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism. Thromb Haemost 2009;101:197–200.Web of ScienceCrossrefPubMedGoogle Scholar

  • 8.

    Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing inemergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004;2:1247–55.PubMedCrossrefGoogle Scholar

  • 9.

    Kilinc G, Dogan OT, Berk S, Epozturk K, Ozsahin SL, Akkurt I. Significance of serum cardiac troponin I levels in pulmonary embolism. J Thorac Dis 2012;4:588–93.Web of SciencePubMedGoogle Scholar

  • 10.

    Perrier A, Desmarais S, Goehring C, de Moerloose P, Morabia A, Unger PF, et al. D-dimer testing for suspected pulmonary embolism in outpatients. Am J Respir Crit Care Med 1997;156(2 Pt 1):492–6.CrossrefPubMedGoogle Scholar

  • 11.

    Lankeit M, Jiménez D, Kostrubiec M, Dellas C, Kuhnert K, Hasenfuß G, et al. Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism. Eur Respir J 2014;43:1669–77.CrossrefWeb of SciencePubMedGoogle Scholar

  • 12.

    Schulz-Hardt S, Frey D, Lüthgens C, Moscovici S. Biased information search in group decision making. J Pers Soc Psychol 2000;78:655–69.PubMedCrossrefGoogle Scholar

  • 13.

    Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Acad Med 2017;92:23–30.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 14.

    Kahneman D, Tversky A. On the reality of cognitive illusions. Psychol Rev 1996;103:582–91.PubMedCrossrefGoogle Scholar

  • 15.

    Mamede S, Schmidt HG, Rikers RM, Custers EJ, Splinter TA, van Saase JL. Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert. Psychol Res 2010;74:586–92.PubMedCrossrefWeb of ScienceGoogle Scholar

About the article

Received: 2019-04-09

Accepted: 2019-06-10

Published Online: 2019-07-20

Published in Print: 2019-11-26


Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Ethical approval/informed consent: Not applicable.


Citation Information: Diagnosis, Volume 6, Issue 4, Pages 387–392, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2019-0030.

Export Citation

©2019 Walter de Gruyter GmbH, Berlin/Boston.Get Permission

Comments (0)

Please log in or register to comment.
Log in